Participatory approaches to programme design, planning and early implementation: experiences from a safe surgery project in Nigeria.

MOMENTUM Safe Surgery in Family Planning and Obstetrics is a global project that strengthens surgical ecosystems through partnership with country institutions. In Nigeria, the project implements in Bauchi, Ebonyi, Kebbi and Sokoto states and the Federal Capital Territory, focusing on surgical obstetrics, holistic fistula care and female genital mutilation/cutting prevention and care. The project utilized participatory approaches during its design, planning and early implementation phases. During the design phase, the project employed a co-creation process featuring a desk review, key informant interviews and stakeholder workshops at community, facility, and government levels to actively listen to, identify and incorporate local perspectives on surgical ecosystem gaps and priorities. Initial findings, shared at state- and national-level workshops, helped collectively identify and prioritize context-specific interventions. The resulting co-created workplan features interventions to strengthen surgical services based on the National Surgical, Obstetrics, Anaesthesia and Nursing Plan (NSOANP). Upon workplan approval, the planning phase involved meeting with each State Ministry of Health (MOH) to prioritize workplan interventions for implementation and to define the finer details needed to drive early implementation processes. Preliminary achievements during early implementation include state commitments to include a costed facility NSOANP in 2023 annual operational plans, mitigation of health facility staffing shortages and review of national fistula and surgical Health Management Information System indicator data flow and advocacy to the Federal MOH resulting in improved fistula data quality and availability. Well-established state and national systems, structures, policies and guidelines enable this programming approach. Since communication between institutional actors is often limited, these approaches necessitate building and maintaining relationships and knowledge-sharing, which requires a significant up-front time investment that must be balanced with donor/partner desires for rapid deliverables. Linking different actors within the health system together through co-creation/co-implementation represents a crucial step in building sustainable country ownership and oversight for surgical ecosystems strengthening interventions.

Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review.

BACKGROUND: Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs). OBJECTIVES: To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature. SEARCH STRATEGY: The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS. SELECTION CRITERIA: English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included. DATA COLLECTION AND ANALYSIS: A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework. MAIN RESULTS: Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels. CONCLUSIONS: There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.

Down But Not Out: Vasectomy Is Faring Poorly Almost Everywhere-We Can Do Better To Make It A True Method Option.

INTRODUCTION: Demand for vasectomy-1 of 2 contraceptive methods for men-has been low, with deep-seated myths, misconceptions, and provider bias against it widespread. Programmatic attention and donor funding have been limited and sporadic. METHODS: We analyzed vasectomy use in 84 low- and middle-income countries (LMICs) plus the 11 high-income countries with vasectomy prevalence above 1%. These 95 countries comprise 90% of the world's population. Data come from United Nations survey compilations, population estimates, and gender inequality rankings. We also reviewed recent articles on vasectomy and analyses of chronic challenges to vasectomy service provision. RESULTS: Vasectomy use is 61% lower now than 2 decades ago. Of 922 million women using contraception worldwide, 17 million rely on vasectomy-27 million fewer than in 2001. In contrast, 219 million women use tubectomy-8 million more than in 2001. Of 84 LMICs, 7 report vasectomy prevalence above 2%. In 56 LMICs, no more than 1 in 1,000 women relies on vasectomy. Female-to-male disparities in permanent method use widened globally, from 5:1 to 13:1, and are much higher in some regions and countries (e.g., 76:1 in India). Countries with the highest vasectomy prevalence are among those with the highest gender equality and vice versa. CONCLUSION: Vasectomy use is surprisingly low globally and declining. Use remains negligible in almost all LMICs, reflecting low demand and program priority. For vasectomy to become an accessible, rights-based option, program efforts need to be holistic, ensuring an enabling environment while coordinating demand- and service-focused efforts. Vasectomy champions at all levels should be supported on a sustained basis. On the demand side, harnessing mass and social media to increase accurate knowledge and normalize vasectomy as a method and service will be particularly valuable. Evidence from Bolivia suggests relatively few trained providers and procedures could result in a country's attaining 1% vasectomy prevalence.

Predictors of neonatal mortality: development and validation of prognostic models using prospective data from rural Bangladesh.

Objective: To assess the extent to which maternal histories of newborn danger signs independently or combined with birth weight and/or gestational age (GA) can capture and/or predict postsecond day (age>48 hours) neonatal death. Methods: Data from a cluster-randomised trial conducted in rural Bangladesh were split into development and validation sets. The prompted recall of danger signs and birth weight measurements were collected within 48 hours postchildbirth. Maternally recalled danger signs included cyanosis (any part of the infant's body was blue at birth), non-cephalic presentation (part other than head came out first at birth), lethargy (weak or no arm/leg movement and/or cry at birth), trouble suckling (infant unable to suckle/feed normally in the 2 days after birth or before death, collected 1-month postpartum or from verbal autopsy). Last menstrual period was collected at maternal enrolment early in pregnancy. Singleton newborns surviving 2 days past childbirth were eligible for analysis. Prognostic multivariable models were developed and internally validated. Results: Recalling ≥1 sign of lethargy, cyanosis, non-cephalic presentation or trouble suckling identified postsecond day neonatal death with 65.3% sensitivity, 60.8% specificity, 2.1% positive predictive value (PPV) and 99.3% negative predictive value (NPV) in the development set. Requiring either lethargy or weight <2.5 kg identified 89.1% of deaths (at 39.7% specificity, 1.9% PPV and 99.6% NPV) while lethargy or preterm birth (<37 weeks) captured 81.0% of deaths (at 53.6% specificity, 2.3% PPV and 99.5% NPV). A simplified model (birth weight, GA, lethargy, cyanosis, non-cephalic presentation and trouble suckling) predicted death with good discrimination (validation area under the receiver-operator characteristic curve (AUC) 0.80, 95% CI 0.73 to 0.87). A further simplified model (GA, non-cephalic presentation, lethargy, trouble suckling) predicted death with moderate discrimination (validation AUC 0.74, 95% CI 0.66 to 0.81). Conclusion: Maternally recalled danger signs, coupled to either birth weight or GA, can predict and capture postsecond day neonatal death with high discrimination and sensitivity.

GLP-1 RA Treatment Patterns Among Type 2 Diabetes Patients in Five European Countries.

INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a relatively new class of injectable drugs used in the treatment of type 2 diabetes (T2D). This retrospective database study evaluated real-world treatment patterns of T2D patients initiating GLP-1 RAs in Belgium (BE), France (FR), Germany (DE), The Netherlands (NL) and Sweden (SE). METHODS: Adult T2D patients initiating exenatide twice daily (exBID), exenatide once weekly (exQW), liraglutide (LIRA) or lixisenatide (LIXI) during 2013 were identified using the QuintilesIMS (QuintilesIMS, Durham, NC, and Danbury, CT, USA) longitudinal retail pharmacy databases (LRx; BE/FR/DE/NL) and national health register data (SE). Therapy initiation date was termed 'index date.' Eligible patients had ≥180-day pre- and variable follow-up (minimum ≥360 days post-index). Baseline patient and treatment characteristics were assessed. Treatment modification and persistence were evaluated over the 1-year follow-up. Kaplan-Meier (KM) survival curves evaluated stopping of the index therapy (first of discontinuation or switch) over the available follow-up. RESULTS: A total of 4339 exBID, 1499 exQW, 20,955 LIRA and 1751 LIXI patients were included in the analysis (45.1-61.9% female; mean age range 57.1-62.9 years). Mean follow-up ranged from 17.7 to 30.7 months. Across countries/databases, the proportion experiencing a treatment modification at 1-year ranged from 84.1 to 93.8% for exBID, 53.3-73.4% for exQW and 59.5-80.5% for LIRA patients. The proportion of LIXI patients with treatment modification was 55.0% in Belgium (N = 20) and 96.9% in Germany (LIXI taken off the German market in April 2014). In KM analyses, LIRA patients had the lowest proportion stopping therapy, while exBID patients had the highest proportion stopping therapy, across databases, with the exception of LIXI patents. CONCLUSION: Treatment patterns varied among GLP-1 RA patients, and persistence was generally highest among LIRA and lowest among exBID across countries. Longer term data would be useful, given the recent approval of several GLP-1 RA therapies. FUNDING: Eli Lilly and Co., Indianapolis, IN, USA.

Correction: Antisense precision polymer micelles require less poly(ethylenimine) for efficient gene knockdown.

Correction for 'Antisense precision polymer micelles require less poly(ethylenimine) for efficient gene knockdown' by Johans J. Fakhoury, et al., Nanoscale, 2015, 7, 20625-20634.

Antisense precision polymer micelles require less poly(ethylenimine) for efficient gene knockdown.

Therapeutic nucleic acids are powerful molecules for shutting down protein expression. However, their cellular uptake is poor and requires transport vectors, such as cationic polymers. Of these, poly(ethylenimine) (PEI) has been shown to be an efficient vehicle for nucleic acid transport into cells. However, cytotoxicity has been a major hurdle in the development of PEI-DNA complexes as clinically viable therapeutics. We have synthesized antisense-polymer conjugates, where the polymeric block is completely monodisperse and sequence-controlled. Depending on the polymer sequence, these can self-assemble to produce micelles of very low polydispersity. The introduction of linear poly(ethylenimine) to these micelles leads to aggregation into size-defined PEI-mediated superstructures. Subsequently, both cellular uptake and gene silencing are greatly enhanced over extended periods compared to antisense alone, while at the same time cellular cytotoxicity remains very low. In contrast, gene silencing is not enhanced with antisense polymer conjugates that are not able to self-assemble into micelles. Thus, using antisense precision micelles, we are able to achieve significant transfection and knockdown with minimal cytotoxicity at much lower concentrations of linear PEI then previously reported. Consequently, a conceptual solution to the problem of antisense or siRNA delivery is to self-assemble these molecules into 'gene-like' micelles with high local charge and increased stability, thus reducing the amount of transfection agent needed for effective gene silencing.

Barriers faced by Ugandan university students in seeking medical care and sexual health counselling: a cross-sectional study.

BACKGROUND: Meeting the medical and sexual health care needs of young people is crucial for sustainable development. In Uganda, youth are faced with a number of challenges related to accessing medical care and sexual health counselling services. This study sought to investigate the barriers faced by Ugandan university students in seeking medical care and sexual health counselling. METHODS: This study is part of a cross-sectional survey conducted in 2005 among 980 students at Mbarara University of Science and Technology. Data was collected by means of a self-administered 11-page questionnaire. The barriers encountered by respondents in seeking medical care and sexual health counselling were classified into three categories reflecting the acceptability, accessibility, or availability of services. RESULTS: Two out of five students reported unmet medical care needs, and one out of five reported unmet sexual health counselling needs. Acceptability of services was the main barrier faced by students for seeking medical care (70.4%) as well as for student in need of sexual health counselling (72.2%), regardless of age, gender, self-rated health, and rural/peri-urban or urban residence status. However, barriers differed within the various strata. There was a significant difference (p-value 0.01) in barriers faced by students originally from rural versus peri-urban/urban areas in seeking medical care (acceptability: 64.8%/74.5%, accessibility: 22.0% /12.6%, availability 13.2%/12.9%, respectively). Students who reported poor self-rated health encountered barriers in seeking both medical care and sexual health counselling that were significantly different from their other counterparts (p-value 0.001 and 0.007 respectively). CONCLUSIONS: Barriers faced by students in seeking medical and sexual health care should be reduced by interventions aimed at boosting confidence in health care services, encouraging young people to seek early treatment, and increasing awareness of where they can turn for services. The availability of medical services should be increased and waiting times and cost reduced for vulnerable groups.

Stroke incidence, recurrence, and case-fatality in relation to socioeconomic position: a population-based study of middle-aged Swedish men and women.

BACKGROUND AND PURPOSE: Low socioeconomic status is associated with increased incidence of stroke. This study investigated stroke incidence, recurrence, and case-fatality after stroke among middle-aged Swedish men and women and whether this association differs by gender or stroke subtype. METHODS: A total of 69 625 (49% men) citizens, aged 40 to 65 years, living in the city of Malmö in 1990 were studied in relation to total annual income and occupation class, ie, 2 indicators of socioeconomic status. Incidence of first-ever stroke, stroke recurrence, and case-fatality (death within 28 days or 1 year after stroke) were studied over 10 years of follow-up. RESULTS: During the follow-up, a total of 1648 subjects developed a first-ever stroke of whom 275 also experienced a recurrent stroke. By using Cox regression model with covariate adjustments, the incidence of stroke was significantly increased (relative risk: 1.75, 95% CI:1.36 to 2.25) in women who were in the lowest quartile of income compared with the women being in the highest quartile. Corresponding relative risk in men was 1.29 (1.06 to 1.58). Both in men and women, income was significantly associated with ischemic, but not hemorrhagic, subtypes of stroke. Similar relationships were observed between occupation level and incidence of stroke. In addition, low income was associated with higher 28-day and 1-year fatality rates in men (relative risk: 3.13, 1.35 to 7.24 and 2.17, 1.18 to 4.00, respectively), but not in women. In contrast, recurrence of stroke was inversely associated with income only in women. CONCLUSIONS: Incidence of stroke, stroke recurrence, and case-fatality increased with decreasing socioeconomic status; however, this relationship differed by gender and subtype of events.

Children exposed to environmental smoking have a higher antibiotic consumption.

In order to investigate what factors influence antibiotic prescribing, a questionnaire answered by 8700 parents to 4-year-old children in Malmö between 1999 and 2004 was analyzed. 51.3% of the 4-year-old children had been treated with antibiotics. Exposure to environmental smoking, attending day care centers, employment of parents and parents born in Sweden was found to be statistically significant risk factor for antibiotic prescribing. The association between environmental smoking and antibiotic treatment found in this study could be used in information campaigns which might not only lead to a decreased antibiotic prescribing among the children, but also future positive health effects for their parents.

Risk factors for primary intracerebral hemorrhage: a population-based nested case-control study.

PURPOSE: In this population-based study, risk factors for primary intracerebral hemorrhage (PICH) and PICH subtypes were explored in a nested case-control design. METHOD: Risk factors were determined in 22,444 men and 10,902 women (mean age 47 years) who participated in a health-screening programme between 1974 and 1991. 147 subjects with CT or autopsy-verified first-ever PICH during the follow-up period (mean 14 years) were compared with 1,029 stroke-free controls, matched for age, sex and screening-year. RESULTS: As compared to controls, PICH cases had significantly higher blood pressure (135/91 vs. 127/85 mm Hg), triglycerides (1.7 vs. 1.4 mmol/l), BMI (25.5 vs. 24.8) and shorter stature (1.73 vs. 1.74 m). Diabetes (6.9 vs. 2.8 %) and history of psychiatric morbidity (19.7 vs. 11.0 %) were more common in PICH cases and more of them were living alone (35.4 vs. 25.5%). After adjustment in a backward logistic regression model, high systolic blood pressure, diabetes, high triglycerides, short stature and psychiatric morbidity remained significantly associated with PICH. As compared to the control group, high systolic blood pressure was significantly associated both with nonlobar and lobar PICH. Diabetes and psychiatric morbidity were associated with nonlobar PICH. Smoking doubled the risk for lobar PICH, but was unrelated to nonlobar PICH. CONCLUSION: In this prospective population-based study, hypertension, diabetes, height, triglycerides and psychiatric morbidity were risk factors for PICH. Smoking was a risk factor for lobar PICH only.

Seasonal patterns of incidence and case fatality of stroke in Malmo, Sweden: the STROMA study.

BACKGROUND: Studies on the temporal variation in stroke incidence have reported inconsistent results. Few have studied the temporal variations in case fatality. No study on incidence and case fatality of stroke by season in Sweden has been found. This study explores the weekly, monthly and seasonal variations in incidence and 28-day case fatality of stroke. METHODS: A total of 7,129 patients with first-ever stroke during the period 1989-1999 were retrieved from the Stroke Register of Malmo, Sweden. chi(2) test was performed to test the seasonal differences and Poisson regression analysis was used to calculate the case fatality ratios adjusted for sex and age. RESULTS: The stroke cases were on the whole randomly distributed over the study period of 4,017 days. Incidence of all types of stroke, intracerebral hemorrhage and subarachnoid hemorrhage showed no variation by season, month or weekday, but incidence of cerebral infarction for the total population was higher in autumn and winter. Twenty-eight-day case fatality (930 fatal events, 13%) clustered significantly over the study period. Winter emerged as the peak season among men (12.5%), women (17.2%) and total population (15.1%). No consistent variation of incidence and case fatality of stroke by month or weekday was found. CONCLUSION: Case fatality after stroke demonstrates a seasonal variation with a peak in winter. Incidence of stroke showed no consistent association with season, month or weekday.

Marital dissolution is followed by an increased incidence of stroke.

BACKGROUND: Many studies have reported lower mortality in married people. The relation between marital status and incidence of haemorrhagic and ischaemic stroke is unclear. It is largely unknown whether the risk of stroke is increased the first years after divorce or death of spouse. METHODS: Incidence of first-ever stroke (n = 6,184) was followed over 10 years in a cohort consisting of all 40- to 89-year-old inhabitants (n = 118,134) in the city of Malmö, Sweden. Marital dissolution (i.e. divorce or death of spouse) prior to the date of stroke was compared in a nested case-control design (3,134 initially married stroke cases, 9,402 initially married controls). RESULTS: As compared to the married groups, the incidence of stroke was increased in divorced men and women (RR = 1.23, CI: 1.10-1.39 and RR = 1.26, CI: 1.12-1.41, respectively) and widowed men and women (RR = 1.13, CI: 0.99-1.28 and RR = 1.13, CI: 1.02-1.24, respectively) after adjustments for age, country of birth and socioeconomic indicators. The risk of stroke was not increased in never married men. Marital dissolution was followed by increased risk of stroke, which was significant for men (adjusted odds ratio: 1.23, CI: 1.03-1.5) and borderline significant for women below 65 years of age (odds ratio: 1.45, CI: 0.99-2.14). CONCLUSION: The incidence of stroke is increased in divorced and widowed individuals. Never married men do not have an increased incidence. The risk of stroke is elevated during the first years after divorce or death of spouse.

Incidence of stroke and stroke subtypes in Malmö, Sweden, 1990-2000: marked differences between groups defined by birth country.

BACKGROUND AND PURPOSE: The proportion of immigrants has increased in Sweden markedly during the last decades, as in many other Western countries. Incidence of stroke has increased during this period. However, it is primarily unknown whether incidence of stroke and stroke subtypes in Sweden is related to country of birth. METHODS: Incidence of first-ever stroke was followed during 10 years in a cohort consisting of all 40- to 89-year-old inhabitants in the city of Malmö, Sweden (n=118,134). Immigrants from 12 different countries were compared with native-born Swedes. RESULTS: Adjusted for age, sex, marital status, and socioeconomic indicators, the incidence of stroke (all subtypes) was significantly higher among immigrants from former Yugoslavia (relative risk [RR], 1.31; 95% CI, 1.1 to 1.6) and Hungary (RR, 1.33; CI, 1.02 to 1.7). A significantly increased incidence of intracerebral hemorrhage was observed in immigrants from Peoples Republic of China or Vietnam (RR, 4.2; CI, 1.7 to 10.4) and the former Soviet Union (RR, 2.7; CI, 1.01 to 7.3). Immigrants from Finland had a significantly higher incidence of subarachnoid hemorrhage (RR, 2.8; CI, 1.1 to 6.8). A significantly lower incidence of stroke was observed in the group from Romania (RR, 0.14; CI, 0.04 to 0.6). Immigrants from Denmark, Norway, Germany, Chile, Czechoslovakia, and Poland had approximately the same risk as citizens born in Sweden. CONCLUSIONS: In this urban population from Sweden, there are substantial differences in stroke incidence and stroke subtypes between immigrants from different countries. To what extent this could be accounted for by exposure to biological risk factors remains to be explored.